A Case Report and Overview of Familial Cerebral Cavernous Malformation Pathogenesis in an Adult Patient

OBJECTIVE We present a case of a 39 year-old woman who presented with a solitary cavernous malformation hemorrhage without any other lesions, and subsequently presented several months later with a new hemorrhage from a de novo lesion. We discuss mechanisms of paradominant inheritance and haploinsufficiency to describe phenotype expression of familial cavernous malformations. CASE DESCRIPTION The patient presented with unremitting headaches, who had a known history of a solitary cerebral cavernous malformation (CCM) for which she underwent resection several months prior with no evidence of any other CCM lesions seen on post-operative MRI. She has no history of whole brain radiation, family history of cavernous malformations, or prior head trauma. During this hospital visit, she was found to have develop two new lesions in the left fronto-parietal lobe and cerebellum. She was treated with surgical resection of the left frontoparietal lesion, and recovered fully. It is of interest that a patient approaching her fourth decade of life would start to develop formation of multiple de novo cavernous malformations, especially with an absent family history. Paradominant Inheritance and haploinsufficiency are two proposed models of inheritance that can be related to this patient’s disease progression. CONCLUSION The case illustrates an atypical clinical course of a patient with familia

Selection Criteria for Posterior Circulation Stroke and Functional Outcome Following Mechanical Thrombectomy

Objective: 20% of all acute ischemic strokes (AIS) are caused by posterior circulation strokes, which carry an intensified mortality touching 95%. Early recanalization improves outcome as shown by several reports; however, safety, patient selection, and prognostic factors remain lacking. An investigation of the safety and prognostic factors for posterior circulation mechanical thrombectomy (MT) was performed. Methods: A retrospective review of patients presenting with posterior circulation AIS, who underwent MT between 2010 and 2018. Results: Of 443 patients who underwent MT for AIS, 83 patients had posterior circulation strokes. 95% of procedures were conducted under general anesthesia. The median NIHSS upon admission was 19.1. Half of the patients underwent MT 8 hours from symptom onset, and half required a salvage contact thrombus aspiration after a stent retriever trial with an average of two passes for successful recanalization. The time to achieve revascularization was 61.6 minutes. Mortality rate was 28%, and modified Rankin Scale (mRS) \u3c 2 at three months was seen in 40.1% of surviving patients. A higher functional outcome trend (mRS\u3c2) was seen in patients who underwent MT within 8 hours of symptom onset. The overall complication rate was 28%. Regression analysis showed that stroke subtype, baseline NIHSS, and posterior circulation Alberta Stroke Program Early CT Score (pc-ASPECTS) before thrombectomy were independent predictive factors of positive clinical outcomes. Conclusions: MT is an effective intervention for posterior circulation strokes, and long-term functional independence relies upon proper patient selection. Baseline NIHSS and pc-ASPECTS are independent predictive factors

Predictors of Ventriculostomy Infection in a Large Cohort

Introduction: External ventricular drains (EVDs) are neurosurgical devices used to treat hydrocephalus and monitor intracranial pressure. Ventriculostomy-associated infections (VAIs) are a complication of EVD placement associated with increased morbidity and mortality, as well as cost. A previous study at Jefferson reported a decrease in VAI’s with the use of antibiotic-coated catheters. Objective: The aim of this study was to assess the current rate of VAI’s and determine risk factors associated with infections. Methods: Using Epic, the electronic medical records software, we conducted a retrospective review of patients who underwent EVD placement at Thomas Jefferson University Hospital and Jefferson Hospital for Neuroscience between January 2010 and January 2018. Results: During this time period, 1107 EVD’s were placed in 1034 patients. The most common indications for placement were acute subarachnoid hemorrhage (51%), intraparenchymal hemorrhage (15.4%), and brain tumors (9.7%). 38 patients suffered from a VAI, for an infection rate of 0.03%. Patients with VAI’s had a significantly longer duration of EVD placement (19.4 vs. 11.1 days). Risk factors for VAI included CSF leak (OR 2.35), EVD placement greater than 11 days (OR 2.14), and concurrent infection (OR 1.74). There was no association with patient age, sex, initial diagnosis, drain replacement, number of samples drawn, or prophylactic antibiotics. Discussion: Despite the use of antibiotic-coated catheters, VAI’s still remain a prevalent complication of EVD placement. By working to prevent CSF leaks, minimize the duration of EVD placement, and appropriately treat concurrent infections, it may be possible to further lower VAI rates

Mechanical Thrombectomy in Acute Ischemic Stroke Patients Greater than 90 years of age experience in 26 patients in a Large Tertiary Care Center: Outcome comparison with younger patients

Introduction: Several independent randomized control trials have shown the superior efficacy of mechanical thrombectomy for acute ischemic stroke (AIS). However, the elderly has been underrepresented or excluded in these trials. In this study, we investigated the feasibility and safety of mechanical thrombectomy in patients with AIS aged 90 years or greater. Methods: A retrospective review of patients age 90 years or older presenting with AIS who underwent mechanical thrombectomy between 2010 and 2018. Results: Of total 453 patients with AIS, 5.74 % (26) were aged 90 or older, and 69.32 % (314) ranged from 60-89 years of age. Of all baseline characteristics between both groups, there is a significant difference in age, gender, body mass index (BMI), smoking, hyperlipidemia (HLD), atrial fibrillation, and diabetes mellitus. The mean NIHSS upon admission was higher in the nonagenarians (17 vs. 15). Similar proportions of both groups received tPA (57.69%, 15 vs. 42.68%, 134, p=0.14). There was no difference in peri & post-procedural complications, good TICI score (88.46%, 23 vs. 87.58%, 275, p=1.00), “good” mRS scores (34.62%, 4 vs. 49.36%, 155, p=0.40), and mortality (11.54%, 3 vs. 13.06%, 41, p= 0.82). Discussion: Age is one of the factors that affect functional outcome following mechanical thrombectomy. Advancements in catheter techniques, technical experience, and great outcomes with mechanical thrombectomy allow for pushing the envelope to deal with age as one of the factors, rather, than an exclusion criterion. Our results show that mechanical thrombectomy is safe and feasible in nonagenarians

Access-Site Complications in Transfemoral Neuroendovascular Procedures: A Systematic Review of Incidence Rates and Management Strategies

BACKGROUND: The femoral artery is the most common access route for cerebral angiography and neurointerventional procedures. Complications of the transfemoral approach include groin hemorrhages and hematomas, retroperitoneal hematomas, pseudoaneurysms, arteriovenous fistulas, peripheral artery occlusions, femoral nerve injuries, and access-site infections. Incidence rates vary among different randomized and nonrandomized trials, and the literature lacks a comprehensive review of this subject. OBJECTIVE: To gather data from 16 randomized clinical trials (RCT) and 17 nonrandomized cohort studies regarding femoral access-site complications for a review paper. We also briefly discuss management strategies for these complications based on the most recent literature. METHODS: A PubMed indexed search for all neuroendovascular clinical trials, retrospective studies, and prospective studies that reported femoral artery access-site complications in neurointerventional procedures. RESULTS: The overall access-site complication rate in RCTs is 5.13%, while in in non-RCTs, the rate is 2.78%. The most common complication in both groups is groin hematoma followed by access-site hemorrhage and femoral pseudoaneurysm. On the other hand, wound infection was the least common complication. CONCLUSION: The transfemoral approach in neuroendovascular procedures holds risk for several complications. This review will allow further studies to compare access-site complications between the transfemoral approach and other alternative access sites, mainly the transradial approach, which is gaining a lot of interest nowadays

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